Healthcare Provider Details

I. General information

NPI: 1174271092
Provider Name (Legal Business Name): MATTLYN NICOLE EDGECOMBE MA LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MATTLYN NICOLE LOPEZ

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 E ALGONQUIN RD
ALGONQUIN IL
60102-3084
US

IV. Provider business mailing address

1190 E ALGONQUIN RD
ALGONQUIN IL
60102-3084
US

V. Phone/Fax

Practice location:
  • Phone: 224-357-0540
  • Fax:
Mailing address:
  • Phone: 224-357-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.019845
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: